Heart Failure

Question 1

What is the definition of chronic heart failure (CHF)?

Answer 1

Cardiac structural and/or functional abnormality= dec cardiac output/ elevated intracardiac pressure at rest of during stress= typical symptoms (breathlessness/ ankle swelling/ fatigue) and signs (elevated jugular venous pressure, pulmonary crackles, peripheral oedema)

cardiac structure/ function problem= failure of heart to deliver oxygen at rate required for metabolising tissues

1-2% of population -> >10% in over 70 years old

Question 2

What is left ventricular heart failure/ diastolic dysfunction?

Answer 2

Left side of heart needs to work harder to pump the same amount of oxygen rich blood to the body, recieves oxygenated blood from the lungs to the left atrium, which then travels to the left ventricle, which it then pumps to the rest of the body

Question 3

What is right ventricular heart failure/ systolic dysfunction?

Answer 3

Heart needs to work harder to pump the same amount of deoxygenated blood to the lungs, which it recieves from the body, to the right atrium, then to the right ventricle

Question 4

Biventricular heart failure?

Answer 4

Both right and left ventricles fail. They aren’t mutually exclusive.

Question 5

What is the cardiac output?

Answer 5

Litres of the blood the heart pumps through the circulatory system in a minute
CO= Heart rate x stroke volume (vol of blood pumped by the left ventricle expressed in mls)

Question 6

what is the ejection fraction?

Answer 6

% of blood left ventricle can pump out with each contraction, stroke volume (ml) / total volume (110ml)

Question 7

what is systolic heart failure?

Answer 7

when the heart can’t pump blood hard enough- insufficient pumping action/ impaired contraction, ejection fraction <40%, 40-50% borderline

Question 8

what are the causes of systolic dysfunction?

Answer 8

chronic hypertension, ischemic heart disease,
dilated cardiomyopathy,
myocarditis

Question 9

what is diastolic dysfunction?

Answer 9

dec compliance of the ventricle walls= insufficient filling

Question 10

what are the causes of diastolic dysfunction

Answer 10

hypertension with left ventricular hypertrophy
hypertrophic cardiomyopathy
restrictive cardiomyopathy
fibrosis
sarcoidosis
amyloidosis
constrictive pericarditis
hemochromatosis
aging

Question 11

what are the symptoms of heart failure

Answer 11

• SOB- exertion and lying down
• Fatigue and weakness
• Swelling (oedema) in legs, ankles and feet

Left sided failure

• fatigue
• exertional dyspnea
• paroxysmal nocturnal dsypnea
• orthopnea
• fatigue
• tachycarida
• tachypnea
• cyanosis
• confusion
• restlessness

pulmonary congestion

• cough
• crackles
• wheezes
• blood tinged sputum

Question 12

what are the symptoms of right sided heart failure?

Answer 12

fatigue
inc jugular veins
inc peripheral venous pressure
ascites 
dependant edema
weight gain
anorexia and complaints of GI distress 
enlarged liver and spleen
may be secondary to chronic pulmonary problems

Question 13

How to classify heart failure based on symptom severity?

Answer 13

Class 1: cardiac disease but no symptoms and limitations on ordianry physical activity
class 2: cardiac disease with mild symptoms and mild limitations during ordinary activity 
class 3: cardiac disease with severe symptoms which limit activity, only comfortable at rest
class 4- cardiac disease with symptoms severely limiting even at rest

Question 14

What are the signs of left sided heart failure?

Answer 14

• crackles in lung bases initially, then throughout lung fields if left untreated
• displaced apex beat
• gallop rhythm
• and signs of right sided heart failure

Question 15

What are the signs of right sided heart failure?

Answer 15

-raised JVP
-ascites
-organomegaly (liver and spleen)
- lower limb and sacral pitting edema
(( right sided heart failure= blood backed up = swelling to veins, interstital space and organs))

Question 16

What are the investigations for heart failure?

Answer 16

ecg
chest xray
echocardiogram
brain naturetic peptide (BNP) 
cardiomyopathy screen 

maybe: MRI, angiopgraphy, transoesophageal echo, dobutamine stress echo (DSE)

Question 17

what is the time course of heart failure?

Answer 17

acute, chronic, acute on chronic/ decompensated

Question 18

what are the goals of treatment for heart failure?

Answer 18

identify underlying cause + treat,
dec cardiac workload,
dec cardiac stress,
counteract maladaptation,
dec symptoms, improve quality of life (decs hospitalisation)

Question 19

management of acute heart failure?

Answer 19

• sit patient up,
  -high flow oxygen,
• IV diuretics at escelating doses,
• cons IV nitrates (caution in hypotension and heart failure secondary to severe aortic stenosis)
• consider IV opiates and anti-emetics,
• cons inotropic support,
• cons device therapy (intra-aortic balloon pump/ impella device),
  cons referral for left ventricular assist device (bridge or destination therapy) or cardiac transplantation

Question 20

how do you manage chronic heart failure?

Answer 20

diuretics for symptoms
ace inhibitors
beta blockers (not in acute decompensation or patients with signs of pulmonary oedema)
mineralocorticoid receptor antagonist
ivabridine
arni
ismn/hydralazine (if can't take acei or arb)
consider crt/ icd
consider cardiac transplantation